True incidence of all complications following immediate and delayed breast reconstruction

Decoding the Mastectomy SKIN Score: An Evaluation of Its Predictive Performance in Immediate Breast Reconstruction

BACKGROUND

The skin ischemia and necrosis (SKIN) score was introduced to standardize the assessment of mastectomy skin flap necrosis (MSFN) severity and the need for reoperation. The authors evaluated the association between the SKIN score and the long-term postoperative outcomes of MSFN after mastectomy and immediate breast reconstruction.

METHODS

The authors conducted a retrospective cohort study of consecutive patients who developed MSFN after mastectomy and immediate breast reconstruction from January of 2001 to January of 2021. The primary outcome was breast-related complications after MSFN. Secondary outcomes were 30-day readmission, operating room (OR) débridement, and reoperation. Study outcomes were correlated with the SKIN composite score.

RESULTS

The authors identified 299 reconstructions in 273 consecutive patients with mean follow-up time of 111.8 ± 3.9 months. Most patients had a composite SKIN score of B2 (25.0%, n = 13), followed by D2 (17.3%) and C2 (15.4%). We found no significant difference in rates of OR débridement ( P = 0.347), 30-day readmission ( P = 0.167), any complication ( P = 0.492), or reoperation for a complication ( P = 0.189) based on the SKIN composite score. The composite skin score was a poor predictor of reoperation, with an area under the curve of 0.56. A subgroup analysis in patients who underwent implant-based reconstruction revealed no difference in rates of OR débridement ( P = 0.986), 30-day readmission ( P = 0.530), any complication ( P = 0.492), or reoperation for a complication ( P = 0.655) based on the SKIN composite score.

CONCLUSIONS

The SKIN score was a poor predictor for postoperative MSFN outcomes and reoperation. An individualized risk-assessment tool that incorporates the anatomic appearance of the breast, imaging data, and patient-level risk factors is needed.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Two-Stage Implant-Based Breast Reconstruction Using Intraoperative Fluorescence Imaging: A Propensity Score-Matched Analysis

BACKGROUND

Limited comparability between study groups can generate significant selection and observer bias when evaluating the efficacy of the SPY system and fluorescence imaging for implant-based breast reconstruction. In this study, the authors compared the surgical outcomes and complications during the first stage of reconstruction between reconstructions evaluated intraoperatively with fluorescence imaging using the SPY system and clinical assessment using a matched analysis.

METHODS

The authors conducted a retrospective review of patients undergoing total mastectomy and immediate two-stage implant-based breast reconstruction with TEs from January of 2011 to December of 2020. The rate of complication, time for TE-to-implant exchange, and time to start radiotherapy were compared between groups (intraoperative fluorescence imaging versus clinical assessment) using a propensity score-matched analysis.

RESULTS

After propensity score matching, 198 reconstructions were evaluated. There were 99 reconstructions in each group. The median time for TE-to-implant exchange (140 days versus 185 days; P = 0.476) and time to initiate adjuvant radiotherapy (144 days versus 98 days; P = 0.199) were comparable between groups. The 30-day rate of wound-related complications (21% versus 9%; P = 0.017) and 30-day rate of wound-related unplanned interventions were significantly higher in reconstructions evaluated with clinical assessment when compared with the SPY system (16% versus 5%; P = 0.011). A higher 30-day rate of seroma (19% versus 14%; P = 0.041) and hematoma (8% versus 0%; P = 0.004) were found in reconstructions assessed intraoperatively with the SPY system.

CONCLUSIONS

After matching, reconstructions evaluated with fluorescence imaging exhibited a lower incidence of early wound-related complications when compared with clinical evaluation alone. Nonetheless, the Wise pattern for mastectomy was found to be the only independent predictor associated with early wound-related complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Autologous breast reconstruction in low- and middle-income countries (LMICs): a systematic review of current practices and challenges

INTRODUCTION

Efforts to improve global healthcare persist, yet LMICs face challenges accessing surgical care, especially breast reconstruction amidst rising breast cancer cases. This review evaluates the present state and challenges of autologous breast reconstruction in low- and middle-income countries (LMICs).

EVIDENCE ACQUISITION

Utilizing the PRISMA guidelines and the Cochrane Collaboration's standards, databases such as EMBASE, MEDLINE, Cochrane, PubMed, and Google Scholar were examined for studies on breast reconstruction in LMICs (based on the World Bank's 2022-2023 definitions) up to August 2022. Articles and case reports focusing on autologous reconstruction following breast cancer surgery in these regions were incorporated.

EVIDENCE SYNTHESIS

From an initial 288 articles, 19 met the criteria after thorough assessment. These articles documented 4899 patient cases from LMICs, with the breakdown being: 11 on LD flaps, nine on TRAM flaps, eight on DIEP flaps, two on TDAP flaps, and one on TMG flap. Flap necrosis emerged as the prevalent complication in four studies.

CONCLUSIONS

While autologous breast reconstruction presents superior aesthetic benefits without notable long-term economic setbacks, its adoption in LMICs is limited. This is partly due to the domination of implant-based methods among patients and surgeons, selected due to convenience. The scarcity of concrete evidence and standardized metrics in LMICs clouds the understanding of this procedure. Despite its advantages, awareness is low, necessitating more training and awareness campaigns. Uniform reporting, quality data, and financial analysis can provide a comprehensive LMIC understanding, aiding future research.

The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis

BACKGROUND

A variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aims to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point.

METHODS

We reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, and surgical and medical complications.

RESULTS

A total of 21,560 patients were included: 11,237 (52%) implant-based (9791/87% immediate, 1446/13% delayed) and 10,323 (48%) autologous (8378/81% immediate, 1945/19% delayed). Complications occurred in 3666 (17%) patients (implant-based: n = 1112/11% immediate, n = 64/4.4% delayed cohorts; Autologous: n = 2073/25% immediate, n = 417/21% delayed cohorts). In propensity score weighting (PSW) analyses, immediate BR was associated with significantly more complications than delayed BR (p < 0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results.

CONCLUSION

At the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients' eligibility in a case-by-case workup.

Frail but Resilient: Frailty in Autologous Breast Reconstruction is Associated with Worse Surgical Outcomes but Equivalent Long-Term Patient-Reported Outcomes

BACKGROUND

Frailty is associated with higher risk of complications following breast reconstruction, but its impact on long-term surgical and patient-reported outcomes has not been investigated. We examined the association of the five-item modified frailty index (MFI) score with long-term surgical and patient-reported outcomes in autologous breast reconstruction.

PATIENTS AND METHODS

We conducted a retrospective cohort study of consecutive patients who underwent mastectomy and autologous breast reconstruction between January 2016 and April 2022. Primary outcome was any flap-related complication. Secondary outcomes were patient-reported outcomes and predictors of complications in the frail cohort.

RESULTS

We identified 1640 reconstructions (mean follow-up 24.2 ± 19.2 months). In patients with MFI ≥ 2, the odds of surgical [odds ratio (OR) 2.13, p = 0.023] and medical (OR 17.02, p < 0.001) complications were higher than in nonfrail patients. We found no significant difference in satisfaction with the breast (p = 0.287), psychosocial well-being (p = 0.119), or sexual well-being (p = 0.314) according to MFI score. Chronic obstructive pulmonary disease was an independent predictor of infection (OR 3.70, p = 0.002). Tobacco use (OR 7.13, p = 0.002) and contralateral prophylactic mastectomy (OR 2.36, p = 0.014) were independent predictors of wound dehiscence. Dependent functional status (OR 2.36, p = 0.007) and immediate reconstruction (compared with delayed reconstruction; OR 3.16, p = 0.026) were independent predictors of skin flap necrosis. Dependent functional status was also independently associated with higher odds of reoperation (OR 2.64, p = 0.011).

CONCLUSION

Frailty is associated with higher risk of complications in breast reconstruction, but there is no significant difference in long-term patient-reported outcomes. MFI should be considered in breast reconstruction to improve outcomes in high-risk frail patients.

Reducing Peri-implant Capsule Thickness in Submuscular Rodent Model of Breast Reconstruction With Delayed Radiotherapy

INTRODUCTION

Capsular contracture remains the most common complication following device-based breast reconstruction, occurring in up to 50% of women who also undergo adjuvant radiotherapy either before or after device-based reconstruction. While certain risk factors for capsular contracture have been identified, there remains no clinically effective method of prevention. The purpose of the present study is to determine the effect of coating the implant with the novel small molecule Met-Z2-Y12, with and without delayed, targeted radiotherapy, on capsule thickness and morphologic change around smooth silicone implants placed under the latissimus dorsi in a rodent model.

METHODS

Twenty-four female Sprague Dawley rats each had 2 mL smooth round silicone breast implants implanted bilaterally under the latissimus dorsi muscle. Twelve received uncoated implants and twelve received implants coated with Met-Z2-Y12. Half of the animals from each group received targeted radiotherapy (20 Gray) on postoperative day ten. At three and 6 months after implantation, the tissue surrounding the implants was harvested for analysis of capsular histology including capsule thickness. Additionally, microCT scans were qualitatively analyzed for morphologic change.

RESULTS

Capsules surrounding Met-Z2-Y12-coated implants were significantly thinner (P = 0.006). The greatest difference in capsule thickness was seen in the irradiated 6-month groups, where mean capsule thickness was 79.1 ± 27.3 μm for uncoated versus 50.9 ± 9.6 μm for Met-Z2-Y12-coated implants (P = 0.038). At the time of explant, there were no capsular morphologic differences between the groups either grossly or per microCT.

CONCLUSIONS

Met-Z2-Y12 coating of smooth silicone breast implants significantly reduces capsule thickness in a rodent model of submuscular breast reconstruction with delayed radiotherapy.

Short-Term Quality of Life after Autologous Compared with Alloplastic Breast Reconstruction: A Prospective Study

BACKGROUND

The aim of this prospective multicenter study was to evaluate whether autologous breast reconstruction (BR) leads to lower short-term quality of life (QoL) compared with alloplastic BR, due to the more physically demanding surgery and increased risk of severe complications of autologous BR.

METHODS

Changes in QoL after BR were measured in this prospective multicenter study using the BREAST-Q questionnaire, which was administered preoperatively and at 6 weeks and 6 months postoperatively. Characteristics and complications, classified according to Clavien-Dindo, were compared between alloplastic and autologous groups. Profile plots and generalized linear regression models were constructed to analyze the BREAST-Q subscales over time for both BR groups.

RESULTS

Preoperatively, women undergoing autologous BR scored lower on all BREAST-Q scales compared with women undergoing alloplastic BR, regardless of whether they underwent immediate or delayed BR. Women undergoing autologous BR scored higher at 6 weeks and 6 months postoperatively on the Satisfaction with Breasts ( P = 0.001), Psychosocial Well-Being ( P = 0.024), and Sexual Well-Being ( P = 0.007) subscales. Postoperative Physical Well-Being: Chest score was similar between the groups ( P = 0.533). Clavien-Dindo grade III or higher complications occurred more often among women in the autologous group (27% versus 12%, P = 0.042). Complications were not associated with worse BREAST-Q scores on any of the subscales.

CONCLUSIONS

In contrast to the authors' expectations, and despite the higher incidence of severe complications and lower preoperative breast satisfaction and QoL scores, women undergoing autologous BR had higher levels of breast satisfaction and psychosocial and sexual well-being, both at 6 weeks and 6 months after BR, compared with women undergoing alloplastic BR.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

A Comparison of Postoperative Outcomes Between Immediate, Delayed Immediate, and Delayed Autologous Free Flap Breast Reconstruction: Analysis of 2010-2020 NSQIP Data

BACKGROUND

 While many factors influence decisions related to the timing between mastectomy and flap-based breast reconstruction, there is limited literature comparing postoperative complications between immediate (IBR), delayed immediate (DIBR), and delayed (DBR) reconstruction modalities. Using the National Surgical Quality Improvement Program (NSQIP), we sought to compare postoperative complication rates of each timing modality.

METHODS

 The NSQIP 2010-2020 database was queried for patients who underwent free flap breast reconstruction. Cases were categorized to include mastectomy performed concurrently with a free flap reconstruction, removal of a tissue expander with free flap reconstruction, and free flap reconstruction alone which are defined as IBR, DIBR, and DBR, respectively. The frequency of postoperative outcomes including surgical site infection (SSI), wound dehiscence, intraoperative transfusion, deep venous thrombosis (DVT), and return to operating room (OR) was assessed. Overall complication rates, hospital length of stay (LOS), and operative time were analyzed. Multivariable regression analysis controlling for age, race, BMI, diabetes, hypertension, ASA class, and laterality was performed.

RESULTS

 A total of 7,907 cases that underwent IBR, DIBR (n = 976), and DBR reconstruction (n = 6,713) were identified. No statistical difference in occurrence of SSIs, wound dehiscence, or DVT was identified. DIBR (9%) and DBR (11.9%) were associated with less occurrences of reoperation than IBR (13.2%, p < 0.001). Univariate and multivariate regression analysis demonstrated that DIBR and DBR were associated with a lower odds of complications and shorter operation time versus IBR. No statistically significant differences between DIBR and DBR in surgical complications, LOS, and operative time were identified.

CONCLUSION

 Awareness of overall complication rates associated with each reconstructive timing modality can be used to help guide physicians when discussing reconstructive options. Our data suggests that DIBR and DBR are associated with less overall complications than IBR. Physicians should continue to consider patients' unique circumstances when deciding upon which timing modality is appropriate.

An Antifibrotic Breast Implant Surface Coating Significantly Reduces Periprosthetic Capsule Formation

BACKGROUND

The body responds to prosthetic materials with an inflammatory foreign body response and deposition of a fibrous capsule, which may be deleterious to the function of the device and cause significant discomfort for the patient. Capsular contracture (CC) is the most common complication of aesthetic and reconstructive breast surgery. The source of significant patient morbidity, it can result in pain, suboptimal aesthetic outcomes, implant failure, and increased costs. The underlying mechanism remains unknown. Treatment is limited to reoperation and capsule excision, but recurrence rates remain high. In this study, the authors altered the surface chemistry of silicone implants with a proprietary anti-inflammatory coating to reduce capsule formation.

METHODS

Silicone implants were coated with Met-Z2-Y12, a biocompatible, anti-inflammatory surface modification. Uncoated and Met-Z2-Y12-coated implants were implanted in C57BL/6 mice. After 21, 90, or 180 days, periprosthetic tissue was removed for histologic analysis.

RESULTS

The authors compared mean capsule thickness at three time points. At 21, 90, and 180 days, there was a statistically significant reduction in capsule thickness of Met-Z2-Y12-coated implants compared with uncoated implants ( P < 0.05).

CONCLUSIONS

Coating the surface of silicone implants with Met-Z2-Y12 significantly reduced acute and chronic capsule formation in a mouse model for implant-based breast augmentation and reconstruction. As capsule formation obligatorily precedes CC, these results suggest contracture itself may be significantly attenuated. Furthermore, as periprosthetic capsule formation is a complication without anatomical boundaries, this chemistry may have additional applications beyond breast implants, to a myriad of other implantable medical devices.

CLINICAL RELEVANCE STATEMENT

Coating of the silicone implant surface with Met-Z2-Y12 alters the periprosthetic capsule architecture and significantly reduces capsule thickness for at least 6 months postoperatively in a murine model. This is a promising step forward in the development of a therapy to prevent capsular contracture.

Outcomes of Negative Pressure Wound Therapy on Immediate Breast Reconstruction after Mastectomy

Immediate expander/implant-based breast reconstruction after mastectomy has become more sought after by patients. Although many patients choose this technique due to good aesthetic outcomes, lack of donor site morbidity, and shorter procedure times, it is not without complications. The most reported complications include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, and implant exposure, with an overall complication rate as high as 45%. Closed incision negative pressure therapy (ciNPT) has shown value in wound healing and reducing complications; however, the current literature is inconclusive. We aimed to examine if ciNPT improves outcomes for patients receiving this implant-based reconstruction.

Methods

This is a retrospective single-institution study evaluating the ciNPT device, 3M Prevena Restor BellaForm, on breast reconstruction patients. The study was performed between July 1, 2019 and October 30, 2020, with 125 patients (232 breasts). Seventy-seven patients (142 breasts) did not receive the ciNPT dressing, and 48 patients (90 breasts) received the ciNPT dressing. Primary outcomes were categorized by major or minor complications. Age, BMI, and final drain removal were summarized using medians and quartiles, and were compared with nonparametric Mann-Whitney test. Categorical variables were compared using chi-square or Fisher exact test.

Results

There was a statistically significant reduction in major complications in the ciNPT group versus the standard dressing group (P = 0.0247). Drain removal time was higher in the ciNPT group.

Conclusion

Our study shows that ciNPT may help reduce major complication rates in implant-based breast reconstruction patients.

DIEP flap in breast reconstruction: A morbidity study of bilateral versus unilateral reconstruction

BACKGROUND

The Deep Inferior Epigastric Perforator (DIEP) flap is a modality in breast reconstruction of choice. Despite its well-documented benefits and complications, a lack of evidence remains with regards to the risks of performing a bilateral versus a unilateral reconstruction. As such, we sought to compare the rates of adverse outcomes in the perioperative and postoperative periods associated with a unilateral versus a bilateral DIEP flap breast reconstruction.

METHODS

A retrospective cohort study of 178 consecutive patients undergoing unilateral versus. bilateral deep inferior epigastric perforator flap breast reconstruction was performed at our tertiary care center over a 3-year period. Data on demographics, operative time, intraoperative and postoperative complications, and surgical re-exploration, were extracted for both groups. Statistical analysis was performed on a per-flap basis.

RESULTS

A total of 157 unilateral and 42 bilateral deep inferior epigastric perforator flaps were identified. The rate of intra-operative complications was 12.1% for unilateral versus. 4.8% for bilateral flaps (P=0.26). Total post-operative complications rates were 30.6% for unilateral versus 54.7% for bilateral flaps (P=0.003). Surgical re-exploration was performed in 12.7% of unilateral and 11.9% of bilateral cases (P=0.88). The rate of total flap loss was similar between types of reconstruction, occurring in 2.5% of unilateral vs. 2.4% of bilateral flaps (P=1).

CONCLUSION

This study demonstrates the rate of complications per flap is significantly higher in bilateral versus unilateral deep inferior epigastric perforator flap breast reconstruction. Bilateral DIEP breast reconstruction should be decided on a case-by-case basis.

LEVEL OF EVIDENCE

Prognostic/Risk Study, Level II.

Point-of-Care Tissue Oxygenation Assessment with SnapshotNIR for Alloplastic and Autologous Breast Reconstruction

In breast reconstruction, mastectomy and free flaps are susceptible to vascular compromise and tissue necrosis. The SnapshotNIR device (Kent Imaging, Calgary, AB, Canada) utilizes near-infrared spectroscopy to measure tissue oxygen saturation (StO₂) and hemoglobin concentration. Here, we report on the use of this device for StO₂ monitoring among patients receiving alloplastic or autologous breast reconstruction.

Methods

Patients receiving immediate alloplastic reconstruction after mastectomy or autologous reconstruction were enrolled. Preoperative, intraoperative, and postoperative images were taken of the flaps. StO₂ and hemoglobin were measured at the following locations: superior and inferior breast, free flap skin paddle (when applicable), and un-operated control skin. Linear mixed effects model for repeated measurements was used to model measurements to estimate the area effect difference across time, time effect difference across area, and pairwise comparisons between two areas at each time point.

Results

Thirty-two breasts underwent alloplastic reconstruction; 38 breasts underwent autologous reconstruction. No enrollees developed skin necrosis. StO₂ was highest after mastectomy and closure in alloplastic reconstructions. StO₂ was observed to decline at follow-up in autologous reconstructions. Mean preoperative StO₂ was highest in breasts that had previously undergone mastectomy and alloplastic reconstruction.

Conclusions

The SnapshotNIR device detected normal spatial and temporal differences in tissue oxygenation over the operative course of alloplastic and autologous breast reconstruction. A multi-institutional, prospective clinical trial is needed to determine the sensitivity and specificity of this device for detecting skin flap necrosis.

Implant-Based Breast Reconstruction in the Elderly: Complications and Patient-Reported Outcomes in Women Older Than 70 Years

BACKGROUND

Advanced age is considered by many to be a relative contraindication to breast reconstruction. However, despite increased medical comorbidities and a perception that elderly patients are less concerned with body image, more women older than 70 years are choosing to undergo breast reconstruction. There is a paucity of data to guide reconstructive decision-making and counseling in this population.

OBJECTIVES

The aim of this study was to evaluate patient satisfaction, complication rates, and long-term outcomes in women older than 70 years undergoing implant-based breast reconstruction.

METHODS

A total of 400 patients were identified at the authors' institution and divided into 2 groups: ≥70 and <70 years old. Medical comorbidities, surgical outcomes, and patient-reported outcomes as defined by the BREAST-Q were compared using the χ2 tests for categorical variables and t tests for continuous variables.

RESULTS

The cohort of patients older than 70 years was made up of 25 women, with a mean age of 73 years, and the cohort of patients younger than 70 years was made up of 375 women, with a mean age of 50 years. There was no significant difference in body mass index (P = 0.373), smoking status (P = 0.360), or history of prior ipsilateral radiation (P = 0.508) between the 2 cohorts; however, the elderly cohort was significantly more likely to have diabetes (P = 0.026). Although elderly patients were less likely to undergo bilateral mastectomy (P < 0.001), there was no significant difference in the type of mastectomy, pathological diagnosis, or method of reconstruction. There was no significant difference in complication rates when looking at minor infection (P = 0.553) or major infection (P = 0.553). The 2 groups were equally likely to undergo secondary procedures (P = 0.192). Overall satisfaction rates were high in all BREAST-Q categories in the elderly group and not significantly different when compared with the group of patients younger than 70 years. Matched-pair analysis showed a significant difference with the group of patients older than 70 years having higher levels physical well-being (P < 0.001).

CONCLUSIONS

Immediate breast reconstruction can be performed safely and with similar high satisfaction rates in the elderly population as their younger counterparts. Age alone should not be used as a reason for excluding women from these life-changing operations.

Closed Incision Negative Pressure Therapy in Oncoplastic Breast Surgery: A Comparison of Outcomes

We aim to discern the impact of closed incision negative pressure therapy (ciNPT) on wound healing in the oncoplastic breast surgery population.

Methods

A retrospective analysis was conducted on patients who underwent oncoplastic breast surgery with and without ciNPT in a single health system over 6 years. Oncoplastic breast surgery was defined as breast conservation surgery involving partial mastectomy with immediate volume displacement or replacement techniques. Primary outcomes were rates of clinically significant complications requiring either medical or operative intervention, including seroma, hematoma, fat necrosis, wound dehiscence, and infection. Secondary outcomes were rates of minor complications.

Results

ciNPT was used in 75 patients; standard postsurgical dressing was used in 142 patients. Mean age (P = 0.73) and Charlson Comorbidity Index (P = 0.11) were similar between the groups. The ciNPT cohort had higher baseline BMIs (28.23 ± 4.94 versus 30.55 ± 6.53; P = 0.004), ASA levels (2.35 ± 0.59 versus 2.62 ± 0.52; P = 0.002), and preoperative macromastia symptoms (18.3% versus 45.9%; P ≤ 0.001). The ciNPT cohort had statistically significant lower rates of clinically relevant complications (16.9% versus 5.3%; P = 0.016), the number of complications (14.1% versus 5.3% with one complication, 2.8% versus 0% with >2; P = 0.044), and wound dehiscence (5.6% versus 0%; P = 0.036).

Conclusions

The use of ciNPT reduces the overall rate of clinically relevant postoperative complications, including wound dehiscence. The ciNPT cohort had higher rates of macromastia symptoms, BMI, and ASA, all of which put them at increased risk for complications. Therefore, ciNPT should be considered in the oncoplastic population, especially in those patients with increased risk for postoperative complications.

Factors impacting informed consent in cosmetic breast augmentation

BACKGROUND

For women who undergo cosmetic breast augmentation, their post-operative risk assessment may not match their pre-operative understanding of the involved risks and likelihood of revision surgeries. This may be due to the potential issues surrounding whether patients are being fully informed about all possible risks and related financial implications during the consent phases of patient/doctor consultation.

METHODS

To explore comprehension, risk preference, and perceptions of breast augmentation procedure, we conducted a recorded online experiment with 178 women (18-40 years) who received varying amounts of risk-related information from two experienced breast surgeons in a hypothetical first consultation scenario.

RESULTS

We find patient's age, self-rated health, income, education level, and openness to experience to be significant factors impacting initial breast augmentation risk preferences (before receiving any risk information). Further, more emotionally stable patients perceived greater breast augmentation risks, were less likely to recommend breast augmentation, and were more likely to acknowledge the likelihood for future revision surgery. After providing women with risk-related information we find increases in risk assessment in all treatment conditions, and that increased amounts of risk information do decrease women's willingness to recommend breast augmentation. But that increased risk information does not appear to increase women's assessment of the likelihood of future revision surgery. Finally, we find some participant individual differences (such as education level, having children, conscientiousness and emotional stability) appear to impact risk assessment post receiving risk information.

CONCLUSION

Continuous improvement of the informed consent consultation process is vital to optimising patient outcomes efficiently and cost-effectively. Greater acknowledgement and emphasis on disclosure of related risks and financial burden when complications arise is also important. As such, future behavioural research is warranted into the factors impacting women's understanding both prior to and across the BA informed consent process.

Safety and Efficacy of Extended Postdischarge Venous Thromboembolism Prophylaxis in Microsurgical Breast Reconstruction

Discharging patients on extended postoperative venous thromboembolism (VTE) prophylaxis is trending in microsurgical breast reconstruction (MBR). This study investigated contemporary bleeding and thromboembolic complications after MBR and reported postdischarge enoxaparin outcomes.

Methods

The PearlDiver database was queried for MBR patients who did not receive postdischarge VTE prophylaxis (cohort 1) and MBR patients discharged with enoxaparin for at least 14 days (cohort 2), then queried for hematoma, deep venous thrombosis (DVT), and/or pulmonary embolism. Concurrently, a systematic review was undertaken to identify studies investigating VTE with postoperative chemoprophylaxis.

Results

In total, 13,541 patients in cohort 1 and 786 patients in cohort 2 were identified. The incidence of hematoma, DVT, and pulmonary embolism were 3.51%, 1.01%, 0.55% in cohort 1, and 3.31%, 2.93%, and 1.78% in cohort 2, respectively. There was no significant difference in hematoma between these two cohorts (P = 0.767); however, a significantly lower rate of DVT (P < 0.001) and pulmonary embolism (P < 0.001) occurred in cohort 1. Ten studies met systematic review inclusion. Only three studies reported significantly lower VTE rates with postoperative chemoprophylaxis. Seven studies found no difference in bleeding risk.

Conclusions

This is the first study utilizing a national database and a systematic review to investigate extended postoperative enoxaparin in MBR. Overall, rates of DVT/PE seem to be declining compared with previous literature. The results of this study suggest that there remains a lack of evidence supporting extended postoperative chemoprophylaxis, although the therapy appears safe in that it does not increase bleeding risk.

Using Clinical Measurements to Predict Breast Skin Necrosis: A Quantitative Analysis

BACKGROUND

Breast skin necrosis can lead to poor healing, reoperation, and unaesthetic reconstructive outcomes after mastectomy. Furthermore, the prolonged recovery can delay adjuvant oncologic regimens. This study aims to explore the role of breast surface area as a risk factor for mastectomy skin flap necrosis and to identify predictive clinical measurements.

METHODS

The authors retrospectively identified patients who underwent immediate breast reconstruction (N = 926 breasts) by 2 surgeons at a single institution between 2011 and 2021. Preoperative breast measurements such as nipple-notch (NN) distance, nipple-inframammary fold (NF) distance, chest width (CW), breast circumference (BC), and breast height (BH) were used to estimate breast surface area. Univariate analysis and receiver operating characteristic curves were used to determine predictive measurements and optimal cutoff values.

RESULTS

When approximated using either a cone without base or a half ellipsoid, larger surface area was a significant risk factor for mastectomy skin flap necrosis (P = 0.027 and P = 0.022, respectively). Larger NN, NF, CW, BC, and BH measurements were significant predictors of necrosis (P < 0.05). Surface area (cone without base) greater than 212 cm2, surface area (half ellipsoid) greater than 308 cm2, NN distance greater than 27 cm, NF greater than 8.5 cm, CW greater than 15 cm, BC greater than 29 cm, and BH greater than 10.5 cm are all values shown to increase the incidence of necrosis.

CONCLUSIONS

Larger breast surface area is an independent risk factor for breast skin necrosis. Preoperative breast measurements can be a useful adjunct for predicting necrosis in postmastectomy patients.

The effect of implant loss after immediate breast reconstruction on patient satisfaction with outcome and quality of life after five years - a case-control study

Several advantages have been suggested for immediate breast reconstruction (IBR); however, there is little scientific high-quality evidence confirming those advantages. Disadvantages of IBR, compared to delayed breast reconstruction (DBR), include an increased risk for complications, such as implant loss (prevalence 5-10% vs. 1%). Little is known on how women experience implant loss and how it affects patients' long-term satisfaction and quality of life (QoL). The primary aim of our study was to compare patient satisfaction and QoL of women with implant loss after IBR, with that of women with a successful IBR. Breast-Q, Body Esteem Scale for Adults and Adolescents (BESAA) and Hospital Anxiety and Depression Scale (HADS) were sent to women who had experienced implant loss during the last 10 years. Women of a similar age who were reconstructed, without complications, during the same period were controls. The results suggest that there might be a more permanent negative effect on satisfaction and QoL following implant loss. The proportion of possible cases of depression was higher among patients who had experienced implant loss. The findings could indicate that in patients with an elevated risk for implant loss, the possible benefits with IBR should be carefully balanced against the effects of implant loss.

Breast Malignancies After Mastectomy With Autologous or Implant Reconstruction

There are multiple indications for mastectomy for breast cancer, including extent of tumor, inability to achieve negative margins after re-excision, patient preference, or prevention in women with a high lifetime risk of breast cancer. Multiple types of autologous or implant reconstruction options are available for cosmesis. Although rare, breast cancers after mastectomy can occur, and it is important for both surgeons and radiologists to be aware of the associated risk factors, common locations, and classic imaging features of these malignancies. This article reviews the types of mastectomies, reconstruction options, and information about the location, presentation, and prognosis of cancers in the reconstructed breast.

Outcomes in Hybrid Breast Reconstruction: A Systematic Review

Background and Objectives: Lipofilling is a commonly performed procedure worldwide for breast augmentation and correction of breast contour deformities. In breast reconstruction, fat grafting has been used as a single reconstructive technique, as well as in combination with other procedures. The aim of the present study is to systematically review available studies in the literature describing the combination of implant-based breast reconstruction and fat grafting, focusing on safety, complications rate, surgical sessions needed to reach a satisfying reconstruction, and patient-reported outcomes. Materials and Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol. A systematic review of the literature up to April 2022 was performed using Medline, Embase, and Cochrane Library databases. Only studies dealing with implant-based breast reconstruction combined with fat grafting were included. Results: We screened 292 articles by title and abstract. Only 48 articles were assessed for full-text eligibility, and among those, 12 studies were eventually selected. We included a total of 753 breast reconstructions in 585 patients undergoing mastectomy or demolitive breast surgeries other than mastectomy (quadrantectomy, segmentectomy, or lumpectomy) due to breast cancer or genetic predisposition to breast cancer. Overall, the number of complications was 60 (7.9%). The mean volume of fat grafting per breast per session ranged from 59 to 313 mL. The mean number of lipofilling sessions per breast ranged from 1.3 to 3.2. Conclusions: Hybrid breast reconstruction shows similar short-term complications to standard implant-based reconstruction but with the potential to significantly decrease the risk of long-term complications. Moreover, patient satisfaction was achieved with a reasonably low number of lipofilling sessions (1.7 on average).

Is Elective Nighttime Operation Associated With Adverse Outcomes? Analysis in Immediate Tissue Expander-Based Breast Reconstruction

BACKGROUND

Despite the long-standing presumption that nighttime surgery could affect adverse outcomes, its association independent of patient's general condition and disease severity remains unclear. We hypothesized that conducting elective surgery for subjects with good physical status at nighttime was not associated with increased risks of postoperative complications and aimed to examine it in tissue-expander-insertion (TEI) operation for breast reconstruction.

METHOD

Patients who underwent immediate unilateral TEI-based breast reconstruction between 2014 and 2019 were enrolled. They were categorized into 3 groups based on the starting time of the TEI operation: 8 am to 6 pm (group 1), 6 pm to 8 pm (group 2), and after 8 pm (group 3). The postoperative complication rates were compared among the groups. The independent associations of each variable, including the operation starting time and adverse outcomes, were analyzed.

RESULTS

In total, 1458 patients were analyzed, including 970 in group 1, 358 in group 2, and 130 in group 3. The groups showed similar baseline characteristics regarding comorbidities and the American Society of Anesthesiologists classification. Compared with group 1, group 3 was associated with significantly increased rates of overall complications including infection, reoperation, and premature removal of the tissue expander. These differences retained influences in the multivariable analyses. Group 3 showed a significantly longer hospitalization period than the other 2 groups. The complication rates did not differ between groups 1 and 2.

CONCLUSIONS

Conducting TEI operation at nighttime seems to be associated with increased risks of adverse postoperative outcomes compared with conducting it during regular working hours.

Donor Site Satisfaction Following Autologous Fat Transfer for Total Breast Reconstruction

BACKGROUND

With evolving breast cancer survival and patient preferences, it is essential that reconstructive surgeons worldwide continue searching for the best reconstruction technique for patients. Autologous fat transfer (AFT) is a relatively new technique for total breast reconstruction that has already proven to be effective and safe with all advantages of autologous tissue. However, little is known about the aesthetic results and satisfaction concerning donor sites.

OBJECTIVES

The aim of this study was to measure donor site satisfaction following AFT for total breast reconstruction in breast cancer patients.

METHODS

Between May and August of 2021, participants of the BREAST- trial who were at least 24 months after their final reconstruction surgery were invited to complete an additional survey concerning donor sites. The BODY-Q was utilized for data collection. Results of AFT patients were compared with a control group of implant-based reconstruction patients who did not have a donor site.

RESULTS

A total of 51 patients (20 control, 31 intervention) completed the questionnaire. Satisfaction with body did not statistically differ between the groups. The most frequent complaint was contour irregularities (31 reports, 60.8%), with the least favorable donor site being thighs (23 reports, 53.5%) in the AFT group.

CONCLUSIONS

Satisfaction with body did not differ between breast cancer patients receiving AFT or implant-based reconstruction, meaning that large-volume liposuction does not aesthetically affect the utilized donor sites. Nevertheless, reconstructive surgeons should be aware of possible donor site complications, especially contour irregularities at the thighs, and discuss this with their patients.

Combining Breast and Ovarian Operations Increases Complications

BACKGROUND

Breast cancer resulting from a genetic mutations, such as BRCA1 or BRCA2, is seen in 5 to 10 percent of patients. More widespread genetic testing has increased the number of affected women undergoing prophylactic mastectomy and oophorectomy. Recent studies have yielded mixed results regarding complication rates after combined breast and ovarian operations. The authors compared surgical outcomes of breast operations performed in combination with salpingo-oophorectomies or as separate procedures.

METHODS

The authors retrospectively analyzed surgical complications and length of hospital stay in 145 female patients, from which 87 had undergone combined breast surgery and salpingo-oophorectomy, and 58 had undergone these procedures separately. Multivariate logistic regression models were used to calculate odds ratios and 95 percent confidence intervals.

RESULTS

Patients undergoing combined breast and ovarian operations experienced higher rates of overall complications (46.5 percent versus 19 percent; p < 0.001), infections (22.2 percent versus 8.6 percent; p < 0.05), and delayed wound healing (13.2 percent versus 0 percent; p < 0.05) related to the breast surgery, when compared with patients undergoing separate procedures. Multivariate logistic regression analysis confirmed a significant association between combined surgery and overall postoperative complications (OR, 5.87; 95 percent CI, 2.03 to 16.91; p = 0.02). Patients undergoing tissue expander-based breast reconstruction combined with ovarian surgery had significantly longer hospital stays compared to patients undergoing separate procedures (3.5 days versus 1.8 days; p < 0.001).

CONCLUSIONS

The authors' data indicate that combining breast and ovarian operations is associated with a higher risk of postoperative complications related to the breast procedure and increases the duration of hospital stay in patients with tissue expander-based reconstructions. The authors' study provides valuable information for preoperative counseling of patients considering both breast and ovarian surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Prospective Longitudinal Patient-Reported Satisfaction and Health-Related Quality of Life following DIEP Flap Breast Reconstruction: Effects of Reconstruction Timing

BACKGROUND

Without reconstruction, mastectomy alone can produce significant detrimental effects on health-related quality of life. The magnitude of quality-of-life benefits following breast reconstruction may be unique based on timing of reconstruction. Facilitated by the BREAST-Q questionnaire, characterization of how reconstruction timing differentially affects patient-reported quality of life is essential for improved evidence-based clinical practice.

METHODS

Consecutive DIEP flap breast reconstruction patients prospectively completed BREAST-Q questionnaires preoperatively and at two different time intervals postoperatively. The first (postoperative time point A) and second (postoperative time point B) postoperative questionnaires were completed 1 month postoperatively and following breast revision/symmetry procedures, respectively. Postoperative flap and donor-site complications were recorded prospectively. Stratified by timing (immediate versus delayed) of reconstruction, preoperative clinical data, operative morbidity, and BREAST-Q scores were compared at all time points.

RESULTS

Between July of 2012 and August of 2016, 73 patients underwent 130 DIEP flap breast reconstructions. Collectively, breast satisfaction, psychosocial well-being, and sexual well-being scores significantly (p < 0.001) increased postoperatively versus baseline. Chest and abdominal physical well-being scores returned to baseline levels by postoperative time point B. Preoperatively, patients undergoing delayed breast reconstruction reported significantly (p < 0.05) lower breast satisfaction, psychosocial well-being, and sexual well-being scores compared to immediate reconstruction patients. Postoperatively, delayed and immediate reconstruction patients reported similar quality-of-life scores. Outcome satisfaction and flap and donor-site morbidity were similar between groups irrespective of timing of reconstruction.

CONCLUSIONS

In this prospective study, patient-reported outcomes demonstrate significant improvements in breast satisfaction, psychosocial well-being, and sexual well-being among patients following DIEP flap reconstruction. Moreover, preoperative differences in quality-of-life scores among delayed/immediate reconstruction patients were eliminated postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Breast Radiotherapy after Oncoplastic Surgery-A Multidisciplinary Approach

Oncoplastic breast surgery encompasses a range of techniques used to provide equitable oncological outcomes compared with standard breast surgery while, simultaneously, prioritizing aesthetic outcomes. While the outcomes of oncoplastic breast surgery are promising, it can add an extra complexity to the treatment paradigm of breast cancer and impact on decision-making surrounding adjuvant therapies, like chemotherapy and radiotherapy. As such, early discussions at the multidisciplinary team meeting with surgeons, medical oncologists, and radiation oncologists present, should be encouraged to facilitate best patient care.

An Advanced Surgical Dressing for High-risk Patients Undergoing Breast Cancer Surgery: a Case-control Study

Oncological breast surgeries, classified as breast conserving surgery, oncoplastic surgery, and mastectomies (standard or with tissue sparing and reconstruction), are burdened with an overall complication rate up to 33%. Aquacel Ag Surgical is a combined hydrofiber-hydrocolloids dressing. The aim of this study is to evaluate the incidence of surgical site complications in patients presenting with three or more risk factors (or two, of which at least one classified as "high risk"), undergoing breast cancer surgery with/without reconstruction, comparing advanced (Aquacel Ag Surgical) with traditional dressing.

METHODS

This is a retrospective, monocentric, case-control study based at the breast unit of the Città della Salute e della Scienza Hospital of Turin, Italy. Forty-two patients who underwent breast surgeries and met the inclusion criteria were enrolled, from February 1 to July 31, 2018. The primary endpoint was comparing the incidence of surgical site complications (skin alterations, infection, and wound dehiscence) in the two groups. The secondary endpoints were evaluating patient's quality of life, aesthetic outcomes, and compliance to the dressings.

RESULTS

The distribution of risk factors at the baseline between the two groups was balanced, without statistically significant differences. Wound complications' incidence at 1 week was lower in the advanced dressing group (P = 0.015). On the bivariate descriptive analysis, advanced dressing proved to be easier to remove for the operator (P = 0.026). The aesthetic outcomes vouched for better scores in the advanced dressing group.

CONCLUSION

In the presented study Aquacel Ag Surgical dressing reduces surgical site complications in the first week after surgery in patients affected by three or more risk factors (or two with at least one classified as "high risk").

The role of fat grafting on contracted breast implant capsules: A retrospective comparative histological and immunohistochemical study

Capsular contracture, a common complication of breast implant reconstruction following postmastectomy radiotherapy (PMRT), represents a challenge for plastic surgeons. Regenerative surgery with multiple autologous fat grafts (lipobed) before replacing the implant has been proven to be a satisfactory approach in the radio-damaged breast. Currently, in literature, there are no data available on the histological features of irradiated capsules after regenerative surgery. We enrolled 80 patients after immediate subpectoral alloplastic breast reconstruction, with indication for revision surgery due to grade IV capsular contracture developed after PMRT. Forty patients were undergoing multiple fat grafting (lipobed group, mean age 48) and 40 patients were not undergoing multiple fat grafting (non-regenerative surgery (NRS) group, mean age 49). The removed capsules were addressed to histological and immunohistochemical assessment. The capsules of the lipobed group patients compared with NRS group patients showed: a lower mean thickness (602.17 versus 670.43 µm; P = 0.013), a lower collagen fiber alignment (median value of angle deviation: 30.34 versus 18.38; P = 0.001), a lower immunohistochemical positivity for myofibroblasts (α-smooth muscle actin [α-SMA] expression: 12.5% versus 52.5%; P = 0.00), a higher immunohistochemical positivity for estrogen receptor-β (ER-β; 80% versus 20%; P = 0.00), and a lower immunohistochemical positivity for estrogen receptor-α (ER-α; 53.3% versus 16.7%; P = 0.00). The histological and immunohistochemical differences found are possibly due to alterations in the extracellular microenvironment determined by grafted fat.

Utilizing NPWT improving skin graft taking in reconstruction for extended breast skin defects following mastectomy

NPWT fulfill graft taking in complex breast wounds.

Immediate one-stage breast reconstruction for an 85-year-old breast cancer patient using deep inferior epigastric perforator flap surgery

The deep inferior epigastric perforator (DIEP) flap is widely recognized as safe for use as a first-choice option in autologous tissue breast reconstruction; however, DIEP is often not performed for breast reconstruction in the elderly. We report a case of an 85-year-old woman who underwent DIEP flap reconstruction. Immediate reconstruction was performed after mastectomy. The patient successfully underwent DIEP flap reconstruction with no complications. Other options for reconstruction include a latissimus dorsi flap, a transverse rectus abdominis flap and implant-based reconstruction. DIEP flap reconstruction was performed, which does not cause muscle damage and provides sufficient volume. To our knowledge, this study is the first to report DIEP breast reconstruction in a patient over 85 years of age. This case demonstrates the usefulness of DIEP flap reconstruction for elderly patients.

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Breast Reconstruction

INTRODUCTION

Frailty can be quantified using an index score to effectively predict surgical outcomes and complications. The modified frailty index (mFI) score includes 5 patient-specific medical history comorbidities including diabetes mellitus, congestive heart failure, hypertension, chronic obstructive pulmonary disease/pneumonia, and nonindependent functional status. The purpose of our study was to apply the 5-item mFI score to predict and minimize complications in patients undergoing breast reconstruction.

METHODS

The National Surgical Quality Improvement Program was queried for all patients undergoing primary breast reconstruction from 2016 to 2018. Patients were divided based on timing of reconstruction and type of reconstruction: immediate or delayed, and implant based or autologous based. A validated modified fragility score was applied to all patients. Patients were stratified by mFI scores of 0 (no comorbidities), 1 (1 comorbidity), and 2+ (2 or more comorbidities). Patient demographics and 30-day complications rates were recorded.

RESULTS

A total of 22,700 patients were identified. There were 10,673 patients who underwent immediate breast reconstruction, and 12,027 patients who underwent delayed breast reconstruction. A total of 14,159 patients underwent implant-based, and 8541 underwent autologous-based reconstruction. A total of 16,627 patients had an mFI score of 0, 4923 had a mFI score of 1, and 1150 had a mFI score of 2+. Compared with patients with an mFI score of 0, patients with an mFI score of 2 or greater were more likely to develop a postoperative complication (7.2 vs 12.3; P < 0.0001). Patients undergoing immediate reconstruction were more likely to develop a postoperative complications for every mFI category. The most common complications were wound and hematologic related.

CONCLUSION

Patients with higher mFI scores are likely to have an increase in postoperative complications after breast reconstruction. Increasing body mass index increases postoperative complications independent of frailty index scores. Patients with increasing frailty index scores undergoing immediate breast reconstruction have a significantly higher risk of postoperative complications compared with delayed reconstruction.Patients with increasing frailty index scores undergoing autologous breast reconstruction have a significantly higher risk of postoperative complications compared with implant-based reconstruction. High frailty index scores are associated with a higher risk of postoperative complications, reoperation rates, and readmission rates. Patients with higher mFI scores may benefit from a delayed implant-based reconstruction.

The Assessment of Early Complications and Risk Factors Affecting Their Occurrence in Breast Reconstructive Procedures

The presence of postoperative complications may have a significant impact on the outcome of the breast reconstruction. The aim of this study was to investigate early postoperative complications and the risk factors for their occurrence. A prospective analysis was carried out to evaluate surgical outcomes after breast reconstructive surgeries performed over a 2-year period. Procedures included expander/implant (TE/IMP), pedicle transverse rectus abdominis musculocutaneous (pTRAM), and latissimus dorsi (LD) techniques. All adverse events which occurred within 6 weeks of surgery were ranked according to severity based on the contracted Accordion grading system. Outcomes were assessed for their association with surgical, demographic, and clinical variables. Sixty-one consecutive breast reconstruction procedures were analyzed. The overall complication rate was 60.7% (n = 37), and 8 patients (13.1%) required reoperation. The lowest complication rate was observed in implant-based reconstructions (TE/IMP, 18.8%; pTRAM, 72.7%; LD, 78.3%; p = 0.008). Mild complications occurred significantly more often after LD reconstructions (LD, 60.9%; pTRAM, 22.7%; TE/IMP, 12.5%; p = 0.031), while severe complications were significantly more frequent after the pTRAM procedures (pTRAM, 27.3%; TE/IMP, 6.2%; LD, 8.7%; p = 0.047). Severe complications were associated with higher rehospitalization rate (p = 0.010) and longer hospital stay. Study revealed a significant impact of the operative method on the incidence and severity of early complications after breast reconstruction procedures with little effect from other demographic and clinical factors.

A Study on Breast Reconstruction in a Developing Country: A Comprehensive Evaluation of the Techniques and Oncologic Outcomes

BACKGROUND

Breast cancer, with an incidence of 33.2 per 100,000 in Iranian population, is considered as the most common cancer in Iranian women. Nowadays, with the increasing survival rates, breast reconstruction has been integrated into surgical techniques of breast cancer treatment. The aim of this study was to evaluate the current status of breast reconstruction in Iranian population.

PATIENTS AND METHODS

This retrospective study was conducted in Imam Hospital between January 2008 and June 2018. All the patients underwent breast reconstruction surgery. The trend of reconstruction and complication rates were 2 major outcomes. Logistic regression model was used to predict complications. Student t test was used to compare means.

RESULTS

Fifty-five patients underwent 60 autologous breast reconstruction surgeries and 152 patients underwent 193 prosthesis-based reconstruction surgeries. Most of cases were invasive ductal carcinoma ± ductal carcinoma in situ (126 cases, 68%). Among 253 surgeries in 207 patients, 98 cases (38.7%) were 2-stage implant, 91 (36.0%) were 1-stage implant, 3 (1.2%) were acellular dermal matrix + prosthesis, 31 (12.2%) were pedicled transverse rectus abdominis myocutaneous flap, 25 (9.8%) were latissimus dorsi flap ± prosthesis, and 4 (15.8%) were latissimus dorsi flap. Among prosthesis-based reconstructions, chemotherapy could predict the occurrence of complications (odds ratio, 2.87; 95% CI, 1.07-7.68), whereas none of these factors could predict the occurrence of complications in autologous reconstructions. The most prevalent complication was seroma formation (48.5% of all complications). Overall complication rates (including major and minor) were higher among autologous reconstructions compared with prosthesis-based reconstructions (45.8% and 21.1%, respectively, P < 0.001).

CONCLUSIONS

The trend of breast reconstruction is changing in Islamic Republic of Iran as a developing country. Implant-based reconstruction has surpassed autologous reconstructions in recent years. In terms of complications, we observed higher rates among autologous reconstructions.

Strategy for salvaging infected breast implants: lessons from the recovery of seven consecutive patients

Background

In recent years, implant-based breast reconstruction has been performed because of its simplicity, short operation time, and rapid recovery of patients. Several studies have reported treatment methods for implant surgery-related infection, which is a serious complication. The aim of this study was to introduce our strategy for salvaging infected implants and to evaluate its effectiveness.

Methods

The authors performed a retrospective study of 145 cases from 132 patients who underwent implant-based breast reconstruction from January 2012 to December 2018. Empirical antibiotics were immediately administered to patients with suspected infections. The patients then underwent salvage treatment including appropriate antibiotics, ultrasonography-guided aspiration, debridement, antibiotic lavage, and implant exchange through a multidisciplinary approach. Patient demographics, operative data, duration until drain removal, adjuvant treatment, and complications were analyzed.

Results

The total infection rate was 5.5% (8/145). A longer indwelling catheter period and adjuvant treatment were significantly associated with infection. The salvage treatment showed a success rate of 87.5% (7/8). Seven patients who received early aggressive salvage treatment recovered from infection. One patient with methicillin-resistant Staphylococcus aureus, who received salvage treatment 11 days after symptom onset, did not respond to drainage and antibiotic treatment. That patient subsequently underwent explantation.

Conclusions

In implant-based breast reconstruction, prevention of infection is of the utmost importance. However, if an infection is suspected, proactive empirical antibiotic therapy and collaboration with the necessary departments are required. Through a multidisciplinary approach and proactive early management, swift and appropriate salvage should be performed.

Early Postoperative Complications From National Surgical Quality Improvement Program: A Closer Examination of Timing and Technique of Breast Reconstruction

BACKGROUND

Despite the recent surge in rates of immediate breast reconstruction, there is a paucity of large multicenter studies to compare differences in morbidity after immediate versus delayed breast reconstruction. This study used the National Surgical Quality Improvement Program (NSQIP) to study the association between timing of breast reconstruction and complication rates, stratified by reconstructive modality.

STUDY DESIGN

The NSQIP database was used to identify breast reconstructions from 2005 to 2012. Rates of major complications were compared by timing within each reconstructive modality (implant vs autologous). Cohort differences in baseline characteristics and variables associated with increased complication rates were identified in bivariate analyses. A multivariable model was created to compare the association between the timing of reconstruction and major complications.

RESULTS

Of 24,506 postmastectomy reconstructions, 85.8% were immediate, 14.2% were delayed, 84% were implant, and 16% were autologous reconstructions. Overall, 10.0% of patients suffered a major complication. After stratification, only implant reconstructions showed a statistically higher complication rate with immediate (8.8%) reconstruction compared with delayed (5.3%) (odds ratio, 1.7, P < 0.01). There was no significant difference in complication rates between autologous immediate (18.4%) or delayed (19.0%) reconstructions. After controlling for baseline cohort differences and other risk factors, immediate reconstruction remained as an independent significant predictor of major complications in implant reconstructions (odds ratio, 1.8, P < 0.01).

CONCLUSIONS

Immediate rather than delayed breast reconstruction is associated with a significantly higher rate of major complications in implant reconstruction but not in autologous reconstruction. It is important to include these findings in the routine preoperative surgeon-patient discussion of reconstructive options.

Use of Negative-Pressure Wound Therapy With Instillation and Dwell in Breast Reconstruction

SUMMARY

The use of negative-pressure wound therapy (NPWT) has expanded over the last 3 decades, paralleled and documented by an increase in research. This article discusses the evolution and current applications of NPWT in modern breast reconstruction. Negative-pressure wound therapy with instillation and dwell (NPWTi-d) technology can be used to remove infectious material, facilitate salvaging compromised tissue, and stabilize the soft-tissue environment. Published consensus NPWTi-d guidelines can aid in treatment selection and implementation of this new technology. The therapeutic approach of simultaneously removing infectious material and actively improving mastectomy flap perfusion and thickness is a burgeoning concept, and illustrative cases are presented. NPWTi-d preliminary use has led to reconstruction salvage with reproducible early experience and outcomes, and it is hoped that it will raise interest and awareness of this promising application of the technology to improve breast reconstruction outcomes.

Quality of Life After Bilateral Risk-Reducing Mastectomy and Simultaneous Reconstruction Using Pre-Pectoral Silicone Implants

PURPOSE

Bilateral risk-reducing mastectomy (BRRM) can reduce the risk of developing breast cancer by up to 95% in women with increased exposure. Although survival is increased, mastectomies can adversely affect a patient physically, psychologically, and psychosexually. High health-related quality of life (HRQoL) is often achieved after simultaneous breast reconstruction (BR) following BRRM; however, data on the pre- and postoperative results of HRQoL are lacking. Therefore, we investigated the quality of life, esthetic outcome, and patient well-being after BRRM and simultaneous implant-based BR.

PATIENTS AND METHODS

Of the 35 patients who underwent skin-sparing or nipple-sparing mastectomy between May 2012 and December 2017 at a university hospital, only 22 completed the evaluation. Baseline data and data on previous operations and operation techniques were retrieved from the patient's charts. BREAST-Q and short form-36 health survey (SF-36) questionnaires were used to evaluate patient satisfaction and HRQoL.

RESULTS

SF-36 analysis showed a significantly higher score for pain (p=0.043) in our population than in the general female population. Comparing the pre- and postoperative BREAST-Q results, a significant decrease in the physical well-being of the chest (p=0.0179) and a slight improvement in breast satisfaction were observed (p=0.3266). All patients were well-satisfied with the postoperative outcome, reconstruction, and perioperative surgeon care.

CONCLUSION

Bilateral mastectomy with simultaneous BR using pre-pectoral implants is associated with an HRQoL similar to that of the healthy population. Although bilateral mastectomy may have an immense effect on the psychological, physical, and social aspects, immediate BR preserves the outer appearance and improves self-esteem.

Risk Factors for Capsular Contracture: A Retrospective Study in Immediate Reconstruction versus Delayed Reconstruction

Capsular contracture is a common complication among breast implant reconstruction patients. The aim of this study was to assess the duration of and risk factors associated with capsular contracture by comparing 2 reconstruction methods.

Lipotransfer Strategies and Techniques to Achieve Successful Breast Reconstruction in the Radiated Breast

Radiation therapy is frequently a critical component of breast cancer care but carries with it side effects that are particularly damaging to reconstructive efforts. Autologous lipotransfer has the ability to improve radiated skin throughout the body due to the pluripotent stem cells and multiple growth factors transferred therein. The oncologic safety of lipotransfer to the breasts is demonstrated in the literature and is frequently considered an adjunctive procedure for improving the aesthetic outcomes of breast reconstruction. Using lipotransfer as an integral rather than adjunctive step in the reconstructive process for breast cancer patients requiring radiation results in improved complication rates equivalent to those of nonradiated breasts, expanding options in these otherwise complicated cases. Herein, we provide a detailed review of the cellular toxicity conferred by radiotherapy and describe at length our approach to autologous lipotransfer in radiated breasts.

Surgical Outcomes of Mastectomy with Immediate Autologous Reconstruction Followed by Radiation

INTRODUCTION

Timing of autologous reconstruction relative to postmastectomy radiation therapy (PMRT) is debated. Benefits of immediate reconstruction must be weighed against a possibly heightened risk of complications from flap irradiation. We reviewed flap outcomes after single operation plus PMRT in a large institutional cohort.

METHODS

Medical records were reviewed for women who underwent simultaneous mastectomy-autologous reconstruction with PMRT from 2007 to 2016. Primary endpoints were rates and types of radiation-related flap complications and reoperations, whose predictors were assessed by multivariable analysis. A p value < 0.10 was deemed significant to avoid type II error. Non-parametric logistic regression generated a model of PMRT timing associated with probabilities of complications and reoperations.

RESULTS

One-hundred and thirty women underwent 208 mastectomy reconstruction operations, with a median follow up of 35.1 months (interquartile range 23.6-56.5). Forty-seven (36.2%) women experienced radiation-related complications, commonly fat necrosis (44.1%) and chest wall asymmetry (28.8%). Complications were higher among women who received PMRT < 3 months after surgery (46.8% for < 3 months vs. 29.3% for ≥ 3 months; p = 0.06), most of whom received neoadjuvant chemotherapy, and among women treated with internal mammary nodal (IMN) radiation (65.2% vs. 26.4%; p < 0.01); IMN radiation remained strongly associated in multivariable analysis (odds ratio [OR] 5.24; p < 0.01). Thirty-two (24.6%) women underwent 70 reoperations, commonly fat grafting (51.9%) and fat necrosis excision (17.1%). Reoperations were higher among women who received PMRT < 3 months after surgery (48.9 for < 3 months vs. 36.6 for ≥ 3 months; p = 0.19), which was significantly associated in multivariable analysis (OR 0.42; p = 0.08 for ≥ 3 months). The probabilities of complications and reoperations were lowest when PMRT was administered ≥ 3 months after surgery.

CONCLUSIONS

Among a large institutional cohort, immediate autologous reconstruction was associated with similar rates of adverse flap outcomes as historically reported alternatively sequenced protocols. IMN radiation increased risk, while PMRT ≥ 3 months after surgery decreased risk. Additional studies are needed to elaborate the impact of IMN radiation and early PMRT in immediate versus delayed autologous reconstruction.

Oncological safety and complication risks of mastectomy with or without breast reconstruction: A Bayesian analysis

BACKGROUND

Currently, breast cancer patients undergoing mastectomy (MA) have three surgical options: MA only and reconstruction at the time of MA ("immediate," IBR) or at a later time ("delayed," DBR). To assess the oncological safety and complication risks associated with different surgical choices, a systematic review with Bayesian network analysis was conducted.

METHODS

Cochrane library, PubMed/MEDLINE, EMBASE, and the China National Knowledge Infrastructure were systematically searched in November 2019. The odds ratios [OR] were estimated for oncological safety (including disease-free survival, overall survival, local recurrence, and distant metastases) and complication risks (including overall complications, surgical site infection, and lymphedema) among MA, IBR, and DBR groups.

RESULTS

In the included 51 studies (265,522 patients), reconstruction after MA for IBR or DBR was associated with increased overall survival compared to simple MA (DBR vs. MA: OR 4.12, 95% credible interval [CrI] 1.80-10.01; IBR vs. MA: OR 1.75, 95% CrI 1.32-2.32). Additionally, IBR was associated with a decreased distant metastasis rate compared to MA (IBR vs. MA: OR 0.67, 95% CrI 0.51-0.90). However, the risk of overall complications and surgical site infection was higher in the IBR group than in the other two groups (complications, IBR vs. DBR: OR 1.40, 95% CrI 1.01-1.93; surgical site infection, IBR vs. MA: OR 1.77, 95% CrI 1.03-3.13).

CONCLUSIONS

Evidence suggested that breast reconstruction, whether IBR or DBR, does not adversely affect oncological safety in the setting of breast cancer. IBR is associated with an increased risk of overall complications and surgical site infection, but technical advances in this surgical procedure have cumulated over time.

Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients

As indications for radiotherapy in mastectomized patients grow, the need for greater reconstructive options is critical. Preliminary research suggests an ameliorating impact of lipotransfer on irradiated patients with expander-to-implant reconstruction. Herein, we present our technique using lipotransfer during the expansion stage to facilitate implant placement.

Complications After Two-Stage Expander Implant Breast Reconstruction Requiring Reoperation: A Critical Analysis of Outcomes

BACKGROUND

Two-stage expander implant breast reconstruction is commonly performed after mastectomy. Salvage and long-term outcomes after development of complications have not been well described. We examined a single surgeon's experience to study the rate of reoperation secondary to complications after first-stage expander placement and to evaluate their outcomes. Better understanding of salvage techniques may help guide future management.

METHODS

We performed a retrospective analysis of consecutive patients who underwent placement of a tissue expander (TE) for breast reconstruction between December 2006 and August 2015 with the senior author. Patient demographics including age, body mass index, medical comorbidities, history of smoking, and history of radiation to the breast were collected. Surgical factors including timing of reconstruction (immediate vs delayed) and location of TE (total submuscular vs with acellular dermal matrix) were recorded. Complications were analyzed, as were patients who underwent reoperation in the setting of developing a complication.

RESULTS

We analyzed 282 patients who underwent 453 implant-based breast reconstructions. Of these, 39 patients and 45 breasts required a reoperation after development of a postoperative complication. Return to the operating room was associated with higher body mass index (29 vs 24, P < 0.001), higher TE initial fill volume (299 mL vs 169 mL, P < 0.001), and preoperative radiation (31% vs 13%, P = 0.001). Complications resulting in reoperation included infection (60%), mastectomy skin necrosis (27%), and TE extrusion through thin mastectomy skin (11%). The affected TE was removed and exchanged in 17 patients (38%), autologous flap reconstruction occurred in 16 patients (36%), and TE was explanted without replacement in 12 patients (27%).

CONCLUSIONS

Infectious complications including cellulitis and abscess formation accounted for most cases requiring reoperation after TE placement for breast reconstruction. More than a quarter of patients who underwent a reoperation ultimately lost their implants. Patients undergoing two-stage expander implant breast reconstruction should be appropriately counseled regarding the possibility of requiring a reoperation in the setting of developing a complication.

From decision to incision: Ideologies of gender in surgical cancer care

In this paper, I draw on the narratives of 57 individuals whose gender identities and decisions about their bodies trouble the medical protocols for breast and gynecological cancer care. I focus here on the decision-making process for three groups of elective surgeries: hysterectomy, prophylactic bilateral and contralateral mastectomy, and breast reconstruction. These elective surgeries illustrate places in medical interactions where patients and providers rely on frames of gender to determine whether a given surgery is an appropriate option for cancer prevention or care. These cases also explain how patient experiences of medical interactions are shaped by and thus reproduce ideologies of gender through the bodies of patients. While clinical practice and medical decisions are supposedly determined through the principles of evidence-based medicine and patient-centered care, I show that ideas about gender can actually supersede both medical evidence and patient desires for their bodies in the care of gynecological and breast cancers.

Does timing of alloplastic breast reconstruction in older women impact immediate postoperative complications? An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database

BACKGROUND

Alloplastic breast reconstruction is safe in well-selected older women. The impact of timing of surgery on complication rates is unknown. This study aimed to determine the immediate (30-day) postoperative complication rates of older women who underwent immediate (IBR) and delayed breast reconstruction (DBR) with alloplastic techniques.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify women ≥70 years old with in situ or invasive breast cancer who underwent either IBR or DBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality.

RESULTS

A total of 2,085 older women underwent alloplastic breast reconstruction of which 90% and 10% were IBR and DBR, respectively. Both groups had similar median age, body mass index, and frequency of smoking, diabetes mellitus, and steroid use. Tumors were mainly invasive in the IBR group (83.5%) and in situ in the DBR group (83.3%). IBR had significantly longer operative times (median 154 min vs 98 min, p < 0.0001), but equal length of stay (median 3 days vs 3 days, p = 0.1). The 30-day overall morbidity (medical or surgical complication) rate was significantly higher in the IBR group (7.5% vs 1.0%, p < 0.0004). Women with IBR were significantly more likely to develop infectious complications (6% vs 1%, p = 0.002). Cardiac/transfusion, pulmonary, thromboembolic, renal, and neurological morbidity rates were equal between groups. Thirty-day mortality rates were similar across both groups (IBR: 0.05% vs DBR: 0%, p = 0.74).

CONCLUSIONS

While overall thirty-day postoperative complication rates in older women who undergo breast reconstruction were low, there were higher rates of infectious complications in the IBR cohort. The risks and benefits of alloplastic breast reconstruction should be discussed with older women undergoing mastectomy for breast cancer treatment.

Is immediate breast reconstruction safe in women over 70? An analysis of the National Surgical Quality Improvement Program (NSQIP) database

PURPOSE

The safety of immediate breast reconstruction (IBR) in older women is largely unknown. This study aimed to determine the 30-day postoperative complication rates following IBR (implant-based or autologous) in older women (≥ 70 years) with breast cancer and to compare them to younger women (18-69 years).

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was used to identify women with in situ or invasive breast cancer who underwent IBR (2005-2016). Outcomes included 30-day postoperative morbidity and mortality, which were compared across age groups stratified by type of reconstruction.

RESULTS

Of 28,850 women who underwent implant-based and 9123 who underwent autologous reconstruction, older women comprised 6.5% and 5.7% of the sample, respectively. Compared to younger women, older women had more comorbidities, shorter operative times, and longer length of hospital stay. In the implant-based reconstruction group, the 30-day morbidity rate was significantly higher in older women (7.5% vs 5.3%, p < 0.0001) due to higher rates of infectious, pulmonary, and venous thromboembolic events. Wound morbidity and prosthesis failure occurred equally among age groups. In the autologous reconstruction group, there was no statistically significant difference in the 30-day morbidity rates (older 9.5% vs younger 11.6%, p = 0.15). Both wound morbidity and flap failure rates were similar between the two age groups. For both reconstruction techniques, mortality within 30 days of breast surgery was rare.

CONCLUSION

Immediate breast reconstruction is safe in older women. These data support the notion that surgeons should discuss IBR as a safe and integral part of cancer treatment in well-selected older women.

Risk factors and timing of postoperative hematomas following microvascular breast reconstruction: A prospective cohort study

BACKGROUND

Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection. This study aims to identify predictors of hematomas following free-flap breast reconstruction.

METHODS

A prospective study was undertaken of patients undergoing autologous free-flap breast reconstruction over a 4-year period. Precise times to hematoma formation, age, arterial and venous anastomosis time, and anastomosis length were recorded and analyzed for association with time to hematoma formation.

RESULTS

One thousand two hundred twelve flaps were undertaken in 1,070 patients during the period of review. Seventy-one (5.8%) flaps were taken back to theater for hematomas. Immediate reconstruction had a significantly higher hematoma rate compared to delayed reconstruction 7.4% versus 5.2% (p < .001). It is noted that there were two main peaks for time to develop hematomas-less than 4 hr postsurgery and between 12 and 15 hr postsurgery.

CONCLUSION

Hematomas are a complication, which must be managed with prompt return to theater to ensure flap salvage and patient stabilization. Predictors for hematoma are presented, with hematomas most likely encountered within the first 12 hr of surgery.